Questions about alcoholism and withdrawal

[Nurse SMS, MSN, RN]

I am a student nurse working an externship at a local hospital. We had an admitted patient who was/is a long term alcoholic (since childhood). The first day or so the patient had horrible shakes and was a fall risk due to the depth of their tremors, and so needed a lot of assistance, but they were mentally cognizant and appropriate. When I returned a week later (I am PRN), the patient was completely confused, incontinent of both bowel and bladder and had the worst smell I have ever experienced in my life. It pervaded the entire floor and the amount of bathing done for this individual truly did not affect the odor. It did not matter if the door were closed or open, and going into the patient's room set off an immediate visceral desire to get away as fast as possible. I could still taste the scent in my mouth hours after leaving the hospital. It seemed as if the patient were literally rotting from the inside out. I was curious about the smell (which was obviously more than just excretory smells), the decline in mental and physical independence and pretty much anything else I could learn about this. We have not done much with addiction issues yet at school. Is a bad smell like this typical for a detox from alcohol? Is the mental decline also typical? What is the best way to deal with such a bad odor? Will the patient remember any of this later on?

Thank you for reading and helping a newbie get more information. Thanks!

[ER_JEN_RN]

No, this is not a smell associated with detox. I see alot of etoh w/d patients in my particular ED and none have a smell that a serious bath wouldnt fix. If you smell something this severe, I hope you have checked labs for any signs of infection, glucose levels for ketones etc. If your patient smells like they are rotting from the inside out and a bath wont fix it, they really might be literally rotting. The one thing I can tell you is that I regularly see etoh patients who have chronic illness related to their lack of ability/desire to care for themselves. Infection is a huge part of that.

[elkpark]

There is a v. distinctive (and unpleasant) odor of ETOH literally leeching out through the skin that you encounter in long-term, hardcore alcoholics (with liver damage severe enough that their livers are no longer able to effectively process the ETOH they drink). Most people have never encountered the smell unless they've spent time working with long-term alcoholics. However, I wouldn't describe it as smelling like something "rotting."

The change in mental status sounds like the client may be experiencing Wernicke-Korsakoff syndrome, a long-term complication of alcoholism also known as alcoholic encephalopathy. I hope that s/he is receiving appropriate detox tx, including thiamine.

[Nurse SMS, MSN, RN]

This individual started drinking in childhood and would easily be categorized as a long term alcoholic. The smell caused us to check their diaper frequently because it was just hard to tell when they had defecated - it smelled like they were dirty pretty much all the time. I had wondered if it could be due to liver damage and its inability to filter out toxins appropriately anymore.

I appreciate the insight. Caring for this individual has been a learning experience to be sure!

[llltapp]

was a GI bleed ruled out? THAT is a distinctive odor that is common in alcoholics :)

[mentalhealthRN]

yes I was thinking GI as well--long term alcoholics are at risk of all sorts or damage to the GI system from one end to the other. They can have esphogeal varacies, ulcers anywhere in the GI system really from all the years of ETOH so yeah a scoping from both ends would be not a bad idea--colonoscopy and endoscopy(EGD). And if there is serious damage to the liver this can create high amonia levels which can create confusion. Wernicke-Korsakoff too should be ruled out--this is essentially brain damage caused by chronic deficiency of Thiamine. Any pt with ETOH abuse hx should be on thiamine and folic acid as well as a good old multivitamin.

[Whispera, MSN, RN]

It could be lots of things, related or not-related to long term alcoholism. GI bleed, liver damage, ketoacidosis related to pancreatitis, clostridium difficile infection (you'll never forget that smell once you smell it), staph, strep, or other infection, or a combination of the above. The odor could be on top of the odor long-term alcoholics have coming from their skin.

While I think your patient is likely to have Wernicke-Korsakoff, it doesn't happen suddenly, so his acute mental status decline is more likely due to something else, and probably related to what's going on that causes the odor.

Was the patient there for his alcoholism or was that a side-situation? What other medical problems does he have?

[spongebob6286, BSN, RN]

the liver must have been messed up so badly

[Nurse SMS, MSN, RN]

It has been a year since this patient was in, and I don't recall anymore what his initial admission was for, but I sincerely appreciate the feedback on this situation. I graduate in December and am amazed how many clients we see with addictions issues and continue to be intrigued with how that wrench can change the whole picture. THANK YOU!

[shrinkyrn]

What's the ammonia level?? confusion could be related to hepatic encephalopathy, I don't know what you are smelling but look up "fetor hepaticus"......

[Thomas RN]

I am curious as to the treatment the patient was receiving the first time you had the responsibility of caring for him. Was he receiving an aggressive alcohol withdrawal protocol? Possibly valium or librium.

[xtxrn, ASN, RN]

What's the ammonia level?? confusion could be related to hepatic encephalopathy, I don't know what you are smelling but look up "fetor hepaticus"......

That was my immediate thought. And the confusion may be permanent of this is the case.